LCD/NCD Portal

L29186

 

HEALTH AND BEHAVIOR ASSESSMENT INTERVENTION

 

02/02/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Indications

• Medicare will consider the Health and Behavior Assessment/reassessment procedures reasonable and necessary for the patient:

o Who has an underlying physical illness or injury, and

o For whom the purpose of the assessment/reassessment is not for the diagnosis or treatment of mental illness, and

o For whom there is reason to believe that a biopsychosocial factor may be significantly affecting the treatment, or medical management of an illness or an injury, and

o Who is expected to have the capacity to understand or respond meaningfully to the psychological intervention, and

o For whom there is a documented need for psychological support in order to successfully manage his/her physical illness and activities of daily living, and

o For whom the assessment/reassessment is not duplicative of other provider assessments

• In addition, Health and Behavior Reassessment is considered reasonable and necessary for the patient:

o For whom there is a question of a sufficient change in psychological or medical status warranting re-evaluation of his or her capacity to understand or to respond meaningfully to the psychological intervention, and

• Health and Behavior Intervention is considered reasonable and necessary for the patient:

o Who has an underlying physical illness or injury, and

o For whom the purpose of the intervention is not the treatment of mental illness, and

o Who are expected to have the capacity to understand or respond meaningfully to the psychological intervention, and

o Who require psychological intervention to address:

 Non-compliance with the medical treatment plan, or

 The biopsychosocial factors associated with a newly diagnosed physical illness, or an exacerbation of an established physical illness, when such factors affect symptom management and expression, health promoting behaviors, behaviors which place the patient or others at risk for safety, health-related risk-taking behaviors, and overall adjustment to medical illness, and

 For whom the specific psychological intervention (s) and patient outcome goal (s) have been clearly identified

• Health and Behavior Intervention (with the family and patient present) is considered reasonable and necessary for patient and family representative*:

o When the family representative* directly participates in the care of the patient, and

o The psychological intervention with the patient and family is necessary to address biopsychosocial factors that affect compliance with the plan of care, symptom management, health-promoting behaviors, behaviors which place the patient or others at risk for safety, health-related risk-taking behaviors, and overall adjustment to medical illness.

o *Family representative is identified as one of the following:

 Immediate family members (husband, wife, domestic partner, siblings, children, grandchildren, grandparents, mother, father),

 Primary caregiver who provides care on a voluntary, uncompensated, regular, sustained basis, or

 Guardian or health care proxy

Limitations:

• Health and Behavioral Assessment or Intervention are not considered reasonable and necessary to:

o Update or educate the family about the patient’s condition

o Educate non-immediate family members, non-primary care-givers, non-guardians, the non-health care proxy, and other members of the treatment team, e.g., health aides, nurses, physical or occupational therapists, home health aides, personal care attendants and co-workers about the patient’s care plan.

o Treatment-planning with staff

o Mediate between family members or provide family psychotherapy

o Educate diabetic patients and diabetic patients’ family members

o Deliver Medical Nutrition Therapy

o Maintain the patient’s or family’s existing health and overall well-being

o Provision of support services, not requiring the skills of a Clinical Psychologist (CP).

o Provide personal, social, recreational, and general support services. These services may be valuable adjuncts to care; however, they are not psychological interventions. Examples of these services are:

 Stress management for support staff

 Replacement for expected nursing home staff functions

 Recreational services, including dance, play, or art

 Music appreciation and relaxation

 Craft skill training

 Cooking classes

 Comfort care services

 Individual social activities

 Teaching social interaction skills

 Socialization in a group setting

 Retraining cognition due to dementia

 General conversation

 Services directed toward making a more dynamic personality

 Consciousness raising

 Vocational or religious advice

 General educational activities

 Tobacco withdrawal support

 Caffeine withdrawal support

 Visits for loneliness relief

 Sensory stimulation

 Games, including bingo games

 Projects, including shopping outings, even when used to reduce a dysphoric state

 Teaching grooming skills

 Grooming services

 Monitoring activities of daily living

 Teaching the patient simple self-care

 Teaching the patient to follow simple directives

 Wheeling the patient around the facility

 Orienting the patient to name, date, and place

 Exercise programs, even when designed to reduce a dysphoric state

 Memory enhancement training

 Weight loss management

 Case management services including but not limited to planning activities of daily living, arranging care or excursions, or resolving insurance problems

 Activities principally for diversion

 Planning for milieu modifications

 Contributions to patient care plans

 Maintenance of behavioral logs

• Health and Behavior Assessment/Intervention services may only be performed by a clinical psychologist.

 

CPT/HCPCS Codes

 

 

96150 HEALTH AND BEHAVIOR ASSESSMENT (EG, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL OBSERVATIONS, PSYCHOPHYSIOLOGICAL MONITORING, HEALTH-ORIENTED QUESTIONNAIRES), EACH 15 MINUTES FACE-TO-FACE WITH THE PATIENT; INITIAL ASSESSMENT

96151 HEALTH AND BEHAVIOR ASSESSMENT (EG, HEALTH-FOCUSED CLINICAL INTERVIEW, BEHAVIORAL OBSERVATIONS, PSYCHOPHYSIOLOGICAL MONITORING, HEALTH-ORIENTED QUESTIONNAIRES), EACH 15 MINUTES FACE-TO-FACE WITH THE PATIENT; RE-ASSESSMENT

96152 HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; INDIVIDUAL

96153 HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; GROUP (2 OR MORE PATIENTS)

96154 HEALTH AND BEHAVIOR INTERVENTION, EACH 15 MINUTES, FACE-TO-FACE; FAMILY (WITH THE PATIENT PRESENT)

 

 

Documentation Requirements

• Because of the impact on the medical management of the patient’s disease, documentation must show evidence of coordination of care with the patient’s primary medical care provider or medical provider responsible for the medical management of the physical illness that the psychological assessment/intervention was meant to address.

• Evidence of a referral to the Clinical Psychologist by the medical provider responsible for the medical management of the patient’s physical illness must be documented in the medical record for the initial assessment and for reassessment.

• Documentation in the medical record by the Clinical Psychologist (CP) must include:

o For the initial assessment, evidence to support that the assessment is reasonable and necessary, and must include at a minimum the following elements:

 Onset and history of initial diagnosis of physical illness, and

 Clear rationale for why assessment is required, and

 Assessment outcome including mental status and ability to understand or respond meaningfully, and

 Goals and expected duration of specific psychological intervention(s), if recommended.

o For re-assessment, evidence to support that the re-assessment is reasonable and necessary must be documented in detailed progress notes. These detailed progress notes must include the following elements:

 Date of change in mental or physical status

 Clear rationale for why re-assessment is required

 Clear indication of the precipitating event that necessitates re-assessment, and

 Changes in goals, duration and/or frequency and duration of services

o For the intervention service, evidence to support that the intervention is reasonable and necessary must include, at a minimum, the following elements:

 Evidence that the patient has the capacity to understand and to respond meaningfully, and

 Clearly defined psychological intervention planned, and

 The goals of the psychological intervention should be stated clearly

 There should be documentation that the psychological intervention is expected to improve compliance with the medical treatment plan, and

 Rationale for frequency and duration of services

• ICD-9-CM diagnosis code(s) reflecting the physical condition(s) being treated must be present on the claim as the primary diagnosis.

• Documentation to support that the indications of coverage have been met

• For all claims, time duration (stated in minutes) spent in the health and behavioral assessment or intervention encounter should be documented in the medical record, and the quantity billed should reflect 1 unit for each 15 minutes (e.g., one hour equals 4 units of service).

• Medical records need not be submitted with the claim; however, the medical record, (e.g., nursing home record, doctor’s orders, progress notes, office records, and nursing notes), must be available to the Carrier upon request.

Utilization Guidelines

• The initial assessment is limited to a maximum of one hour (4 units) per episode of care.

• A reassessment is limited to a maximum of 15 minutes (1 unit) per day.

• The intervention is limited to a maximum of 30 minutes (2 units) per day.

 

Treatment Logic

• Health and Behavior Assessment procedures are used to identify the psychological, behavioral, emotional, cognitive, and social factors important to the prevention, treatment, or management of physical health problems.

• The focus is not on mental health, but on the biopsychosocial factors important to physical health problems and treatments.

• Health and Behavior Intervention procedures are used to modify the psychological, behavioral, emotional, cognitive and social factors identified as important to or directly affecting the patient’s physiological functioning, disease status, health, and well-being.

• The focus of the intervention is to improve the patient’s health and well-being utilizing cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate specific disease-related problems.

 

Sources of Information and Basis for Decision

 

Other Carriers’ policies (National Heritage Insurance Company) and (Trailblazers).

 

Casciani, J.M. (2003). Advancing the physical well-being of older adults: Mental health and primary care. Vericare Monograph 2.

 

Clarke, W.L., Cox, D.J., & et.al. (1997). The relationship between nonroutine use of insulin, food, and exercise and the occurrence of hypoglycemia in adults with IDDM and varying degrees of hypoglycemic awareness and metabolic control. The Diabetes Educator. (23) 1.

 

Friedman, R., Sobel, D. & et.al. (1995). Behavioral medicine, clinical health psychology, and cost offset. Health Psychology. (14) 6, 509-518.

 

Johnston, M. & Vogele, C. (1993). Benefits of psychological preparation for surgery: a meta -analysis. Annals Behavior Medicine, 15 (4): 245-256.

 

02/02/2009

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

CMS LCD L29186 Health and Behavior Assessment Intervention